The patient was operated by me 28-May-2016 for extruded disk L5-S1 with wide based huge location more to the left with right sciatica. The patient came to the clinic 10 days of surgery and he was doing fine and the wound was clean without sciatica. The patient then came 11-June-2016 telling that he got oozing from the wound with headache without sciatica the last 2 days.

On examination: the wound during examination was clean, but the dressing is wet. Neurologically he was free.

The patient was sent for investigations and despite the fact of no fever, antibiotics were started immediately and he was recommended to keep in bed until the problem was clarified. Revision of his records, there was no data for CSF leak during surgery. The video recording explored more than 10 times showed a small stitch at the upper corner of the dura. This made suspicion that this place was the cause of the CSF leak. Usually if the patient having considerable dural defect I put record about that. In this case the stitch was put even without CSF leak to avoid such possibility.

The lab investigations showed ESR  20mm /h and CRP <55 mg/L. MRI lumbar spine performed 13-June-2016 showing no signs of infection and there is a huge pocket of CSF collection.

The wound was opened. There is CSF leak from the left entry of the previous stitch. The roots were explored and the disc space was also included to exclude other sources of CSF leak. There were no other sources. Using nylon 6 zero the pin-point dural defect was repaired with several stitches, doing this without penetrating the full thickness of the dura. A piece of muscle was included in the repair. The patient was put in head elevated position and Valsalva maneuver was performed to check for CSF leak: it was negative. A TissuePatch was applied over the defect and repair.  Routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ward.

The patient still have an estimated postoperative recurrence around 7%, because the disc space is still not shallow.

This case demonstrate that CSF leak could take place even after 2-3 weeks after surgery. There are triggered factors, such as anticoagulant medication after early period of surgery.  We usually advised the patients not to take baby aspirin for at least for 1 month after surgery, until the scar is strong enough. In this case the patient took Baby aspirin during the early period of surgery.

During surgery, it became clear that the aspirin was the cause of the CSF leak, since the CSF was coming from the previous stitch. The thrombus around it resolved and the CSF came out through the stitch hole. Other triggering factors were obesity and diabetes mellitus.